Provider Demographics
NPI:1669687406
Name:MORNINGSTAR, JIM (PHD)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:
Last Name:MORNINGSTAR
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2728 N PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-3768
Mailing Address - Country:US
Mailing Address - Phone:414-962-0213
Mailing Address - Fax:
Practice Address - Street 1:4200 W GOOD HOPE RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-2250
Practice Address - Country:US
Practice Address - Phone:414-351-5770
Practice Address - Fax:414-351-5760
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI473-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical